Obsessive Compulsive Disorder (OCD): A Guide to Understanding and Relieving Your Intrusive Thoughts and Compulsions

Obsessive compulsive disorder (OCD) is a common neurological disability that can control your life. Something that’s often made fun of by people and misrepresented with the “clean freak” trope, is a serious condition that can be emotionally and physically traumatizing. Defined as being persistent and uncontrollable thoughts, impulses or images that lead to impairment in daily living, OCD can be seriously debilitating and clinically is poorly understood. About 1 in 40 adults and 1 in 100 children will suffer from OCD in the U.S.1 Although it can be managed in some cases, OCD can be a tricky situation depending on what the cause is.

Symptoms

OCD symptoms are defined as obsessions and compulsions that last about an hour a day or that limit your daily activities. Obsessions are any intrusive or persistent thoughts that reoccur to the point where you need to either suppress them or alleviate through a compulsion. Compulsions are any repetitive behaviors that temporarily relieve the stresses and anxieties from the obsessive thoughts. As you can see it becomes difficult as this starts what feels like an endless cycle of persistent thoughts that you need to alleviate through your compulsions.

How does OCD occur in the body?

Mechanisms in OCD are poorly understood right now but there are some connections that seem to be at play when people are experiencing these symptoms. We are gonna go over 4 different mechanisms that can trigger OCD and situations we commonly see at our clinic.

The Brain: Basal Ganglia

The basal ganglia is a commonly associated structure with OCD. It is a central structure in your brain that’s located very deep on top of the brain stem. It is often seen as being in charge of stopping unwanted thoughts and facilitating wanted thoughts. Although the relationship hasn’t been thoroughly studied, OCD symptoms have been seen to decrease when the basal ganglia is stimulated. Parts of the basal ganglia have been seen to have a lower output in people with OCD than those with Parkinson’s disease. This suggests that stimulating these areas or adjacent structures can be a potential treatment for alleviating OCD symptoms.2,3

The Gut: Inflammation

Your GI system has a surprising amount of connections to your brain and the gut-brain axis is becoming increasingly important when addressing mood disorders like OCD. Oftentimes the gut is even referred to as the third brain! About 90% of the serotonin made and circulated throughout the body is made in the digestive tract.4 Your serotonin is in charge of regulating anxiety, happiness and your mood! In a study done by Turna in 2019, they found that people with OCD had a higher prevalence of irritable bowel syndrome (IBS) than people that didn’t. Turna also found that there were decreased levels of specific gut bacteria in people with OCD.5 More and more research is showing the importance in a healthy gut microbiome and its effects on OCD and other mood disorders like anxiety and depression. Chronic inflammation in the gut may contribute to why you’re still experiencing OCD symptoms.

Infections: Autoimmune disease

Sudden onset OCD can occur with infections especially in children. PANS and PANDAS is the neuropsychiatric autoimmune condition that is most commonly associated with abrupt onset of OCD in children. An autoimmune response is when your body’s immune system basically attacks itself. It’s believed that an infection triggers an autoimmune response leading to encephalopathy (inflammation in the brain). Infections like strep, pneumonia, sinusitis, herpes, mono, and others may lead to an autoimmune attack. This inflammation in the brain can cause OCD, tics, anxiety, movement disorders, coordination dysfunction, and mood disorders just to list a few! It’s important to consider this when looking at why you may have OCD, although this is commonly found in children it does not mean that it can’t occur in adults as well.6

Concussions (mTBIs) and Traumatic Brain Injuries (TBIs)

TBIs and mTBIs can trigger OCD in some individuals but it is more uncommon. Usually it’s an abrupt onset, however it can be delayed and happen a few months later. Unfortunately, brain scans like MRIs and CTs may not show any damage to the tissues in the brain so some people might be left with more questions than answers. People with head injuries can experience an increase in brain inflammation just like stated above with infections. Anytime there is trauma or whiplash, the central structures of the brain can be affected (like the basal ganglia). You can think about it as if a sponge is being ringed out and the central structures of that sponge are being torqued and sheared. This also affects the gut-brain axis as any injury to the head can cause issues in the GI system. Depression is also a common comorbidity in people who have OCD after suffering a head injury.7

Are there different types of OCD?

There are no official classifications for OCD currently. Everyone experiences OCD different but there are 4 common categories that people can fall into:

1. Cleaning and contamination
2. Symmetry and ordering
3. Intrusive thoughts and impulses
4. Continuous checking

Although these categories exist, not everyone with OCD will fit into these! It’s important to know that these symptoms can vary widely from person to person.

How do I get diagnosed with OCD? Is there a test I can take?

Currently the only way to be diagnosed with OCD is through the DSM-5 category system. A licensed therapist or psych will have to do an evaluation to see if you meet the criteria listed:

1. Presence of obsessions, compulsions, or both:

a. Obsessions are defined as:

i. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

ii.The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some thought or action (i.e., by performing a compulsion.

b. Compulsions are defined as:

i. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

ii. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

2. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

3. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

4. The disturbance is not better explained by the symptoms of another mental disorder.

5. Specify if:

a. With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.

b. With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.

c. With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.

6. Specify if:

a. Tic-related: The individual has a current or past history of a tic disorder.8

Who’s most affected by OCD?

OCD most commonly appears during childhood around ages 10 but some may develop it later in life. About 2 million people in the U.S. currently have been diagnosed with OCD which accounts for 1 – 3% of the population.1 Although in most articles it states that OCD affects the population equally based on race, gender and age, there hasn’t been many studies done on race or socioeconomic factors in regards to OCD. In a study done by Himle et al (2008), they concluded that occurrence and rate of OCD and other associated psychiatric disorders was very high in the Black population which correlated with greater functional impairments in daily living. They also found that this population was greatly underserved and was not receiving adequate care in regards to medication and treatment.9 It’s important to understand these disparities when looking at data in regards to who’s affected by these conditions as there may be biases. OCD can also affect women more depending on where they are in their cycle and commonly can get worse during the premenstrual phase. Males are more likely to experience tic related comorbidities than women.10

What other conditions or comorbidities can I have with OCD?

People who suffer from OCD often have other disorders that affect them as well. Depression, anxiety, panic disorders, panic attacks, eating disorders, body dysmorphia, tics, tourrettes, and perfectionism are common comorbidities that can work synergistically against you. Especially if we take into account the mechanisms behind OCD some of these make a lot of sense! Many mood disorders can be affected by the gut, infections, and brain injuries so there’s room for there to be overlap with other neurological and psychiatric disorders.

What are my treatment options for OCD?

Medication

Conventionally people with OCD are put on selective serotonin reuptake inhibitors (SSRIs) in order to alleviate OCD symptoms. This is normally used as an antidepressant but can also be used to help reduce obsessions and compulsions. This can be good for some people but there are side effects like any medication and depending on the cause of your OCD it may not address the right system.

Cognitive Behavioral Therapy

People with OCD may try cognitive behavioral therapy (CBT) to manage their OCD symptoms. Usually it involves exposure and response prevention (ERP) which aims to deal with the anxieties related to OCD. This is not practiced by all therapists so make sure you go to someone who has been trained to do this type of therapy. This option can be great for people who have more straightforward cases of OCD.

Deep Brain Stimulation

Deep brain stimulation (DBS) is an invasive treatment option that is gaining some traction due to it helping with harder cases of OCD. With DBS they place electrical devices (similar to a pacemaker) on the brain to target deep structures like the basal ganglia to help alleviate symptoms.2 Overall based on several studies, they’ve noted improvement with anxiety and depression as well as a decrease in obsessions and compulsions. However, there are some adverse effects being noted from the surgery and the electrical stimulations in certain cases.11

Our Approach

At our clinic we address OCD from the three mechanisms listed above. With each case we check blood work and do a full neurological work-up. We utilize different modalities to stimulate and inhibit the areas of the brain that are connected in OCD. We address the gut aspect as well through diet changes to reduce inflammation and dysbiosis. Infections can be tricky but there are certain protocols to managing and killing infections. We also look into any structural complaints that may be aggravated by the increased anxiety a person deals with in OCD. With our approach it is non-invasive and can address the complexities that can cause OCD. Especially those who aren’t having success with conventional therapies, we can be a great option for you. Send us a message here if you’d like to learn more about how we may be able to help you!

References

1. “Facts about Obsessive Compulsive Disorder.” Beyond OCD, beyondocd.org/ocd-facts.
2. Welter, M-L et al. “Basal ganglia dysfunction in OCD: subthalamic neuronal activity correlates with symptoms severity and predicts high-frequency stimulation efficacy.” Translational psychiatry vol. 1,5 e5. 3 May. 2011, doi:10.1038/tp.2011.5
3. Macpherson, Tom, and Takatoshi Hikida. “Role of Basal Ganglia Neurocircuitry in the Pathology of Psychiatric Disorders.” Psychiatry and Clinical Neurosciences, vol. 73, no. 6, 2019, pp. 289–301., doi:10.1111/pcn.12830.
4. Yano, Jessica M et al. “Indigenous bacteria from the gut microbiota regulate host serotonin biosynthesis.” Cell vol. 161,2 (2015): 264-76. doi:10.1016/j.cell.2015.02.047
5. Turna, Jasmine et al. “Higher prevalence of irritable bowel syndrome and greater gastrointestinal symptoms in obsessive-compulsive disorder.” Journal of psychiatric research vol. 118 (2019): 1-6. doi:10.1016/j.jpsychires.2019.08.004
6. “Can You Develop OCD? Abrupt Onset of OCD May Result from an Infection.” Moleculera Labs, www.moleculeralabs.com/can-you-develop-ocd/.
7. Schwarzbold, Marcelo et al. “Psychiatric disorders and traumatic brain injury.” Neuropsychiatric disease and treatment vol. 4,4 (2008): 797-816. doi:10.2147/ndt.s2653
8. Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.13, DSM-IV to DSM-5 Obsessive-Compulsive Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t13/
9. Himle, Joseph A et al. “Obsessive-compulsive disorder among African Americans and blacks of Caribbean descent: results from the National Survey of American Life.” Depression and anxiety vol. 25,12 (2008): 993-1005. doi:10.1002/da.20434
10. “What Are the Racial, Age and Gender Predilections of Obsessive-Compulsive Disorder (OCD)?” Latest Medical News, Clinical Trials, Guidelines – Today on Medscape, 10 Nov. 2019, www.medscape.com/answers/1934139-93618/what-are-the-racial-age-and-gender-predilections-of-obsessive-compulsive-disorder-ocd#qna.
11. Greenberg, Benjamin D et al. “Three-year outcomes in deep brain stimulation for highly resistant obsessive-compulsive disorder.” Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology vol. 31,11 (2006): 2384-93. doi:10.1038/sj.npp.1301165